Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
What is the primary purpose of documenting a patient visit?
✔✔To provide a legal record and support billing
Why is it important to note the complexity of a patient’s medical decision-making?
✔✔It determines the level of service provided and ensures accurate billing
What should a medical assistant do if a provider performs an unusual or new procedure?
✔✔Document it in detail for accurate reporting and reimbursement
Which factor is most important when determining if a service is medically necessary?
✔✔Clinical justification based on patient condition and provider assessment
Why is it important to document the time spent on patient counseling?
✔✔It can affect the level of service and proper reimbursement
1
,What is an add-on service in medical billing?
✔✔A service that is performed in addition to a primary procedure
Why should multiple services provided on the same day be documented separately?
✔✔To ensure each service is accurately recognized and reimbursed
How should a medical assistant handle a patient visit that includes both preventive care and
treatment for an illness?
✔✔Document each service separately with clear descriptions
Why is proper documentation crucial for telehealth services?
✔✔It supports reimbursement and ensures compliance with regulations
What is the purpose of using modifiers in reporting services?
✔✔To give additional information about how, when, or where a service was performed
Why must a phlebotomist or MA confirm the medical necessity of lab tests before drawing
blood?
2
,✔✔To prevent unnecessary procedures and support insurance claims
How should a provider indicate that a procedure was partially completed?
✔✔Document the reason and extent of completion
Why is it important to track the number of visits for chronic disease management?
✔✔It helps monitor patient outcomes and justify ongoing care
What is the difference between a new patient and an established patient visit?
✔✔A new patient has not received services from the provider recently; established patients have
Why should a provider document the patient’s chief complaint accurately?
✔✔It guides care and supports billing and coding decisions
What is the purpose of documenting lab or diagnostic results in a patient’s chart?
✔✔To provide a complete record for treatment decisions and follow-up
How should a medical assistant handle a patient who refuses a recommended procedure?
3
, ✔✔Document the refusal and notify the provider
Why is it important to document procedures performed by other providers?
✔✔To maintain a complete record of care and coordinate treatment
What is the significance of noting the method of service delivery (in-person vs. telehealth)?
✔✔It ensures accurate billing and regulatory compliance
Why should the provider’s progress notes include both assessment and plan?
✔✔To provide a clear rationale for treatment decisions
How should repeated or follow-up procedures be documented?
✔✔Indicate that it is a repeat service and include relevant details
What is the purpose of documenting any complications during a procedure?
✔✔To ensure patient safety, legal protection, and accurate reporting
Why is it important to record the patient’s response to treatment?
4